The child death review procedures in place in England (1) are ideally
placed to address the issues that Kenny and Martin raise in their paper on
drowning and sudden cardiac death (2). Although rare - there were 43
drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may
hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response...
The child death review procedures in place in England (1) are ideally
placed to address the issues that Kenny and Martin raise in their paper on
drowning and sudden cardiac death (2). Although rare - there were 43
drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may
hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response by health
professionals working with the police and other agencies enables
appropriate information to be gathered and analysed to clarify the causes
and contributory factors, to support the family, and to identify lessons
to be learnt for prevention. This will include a thorough review of the
circumstances of death, and a detailed medical and family history. This
process should help to highlight factors that may otherwise have been
hidden. This is important, not just for the grieving parents, but also to
identify potential genetic or other risks to the family, and public health
concerns for the wider community. Information gained through the rapid
response, together with a rigorous autopsy, is essential for the coroner,
who can only reach a verdict on the basis of the information provided.
By reviewing every child's death in their area, the multi-agency
child death overview panels provide a further opportunity to consider that
information and to identify issues, patterns and discrepancies that may
help prevent future child deaths. Although it has not yet been achieved,
regional or national collation of data from these panels would achieve the
kind of overview of these deaths that Kenny and Martin call for.
References
1. Sidebotham P, Pearson G. Responding to and learning from childhood
deaths. BMJ 2009;338: 531
2. Kenny D, Martin R. Drowning and sudden cardiac death. Archives of
Disease in Childhood 2011; 96: 5-8
3. Office for National Statistics. DR_09 Mortality statistics: deaths
registered in 2009. London: ONS, 2010
Conflict of Interest:
I am involved in research and training in relation to child death review. I have no competing financial interests.
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified ran...
Modi and McIntosh [1] discuss over-regulation of clinical trials and
the small number of large neonatal multicentre trials carried out in the
UK in 2006.
As there is no single and exhaustive repository of data about UK
trials, it is difficult to determine exactly the level of trial activity
at that time. We can provide data which include 2006 from a survey of
level 2 and 3 neonatal units which identified randomised trials conducted
in the UK in 2002-06. As part of the BRACELET (Bereavement and Randomised
Controlled Trials) Study questionnaires were sent to 220 neonatal units;
191(86.8%) responded, of which 149 were eligible (82 Level 2, 67 Level 3).
Seventy-six units enrolled 3137 neonates in one or more of 36 identified
trials in 2002-06 (10 international, 14 UK multicentre, 12 single centre);
85% (N=2657) were enrolled into multicentre trials [2]. Our parallel
paediatric survey showed a much smaller proportion (55% N=116) enrolled
into multicentre trials in this setting.
We categorised interventions as drugs and foods (including blood
products, anaesthesia, oxygen, food supplements) (n=19); physical
therapies (including cooling, heating, mechanical ventilation, surgery)
(n=15); other (including monitoring, parenting support (n=2)).
We are unable to disaggregate individual years within 2002-06 so
cannot show trends but it is clear that, in addition to INIS, NIRTURE and
PROGRAMS, there were other albeit smaller trials assessing medicinal and
other interventions in the UK.
These figures provide a recruitment baseline for neonatal trials
around the time of the regulatory and structural changes to the UK
research environment considered by Modi and McIntosh. Future studies may
be able to determine empirically whether the number of research-active
units and participants recruited increases, decreases or remains stable in
the aftermath.
[1]Neena Modi, Neil McIntosh. The effect of the neonatal Continuous
Negative Extrathoracic Pressure (CNEP) trial enquiries on research in the
UK. Arch Dis Child published 25 January 2011, 10.1136/adc.2010.188243
[2] Snowdon C, Harvey SE, Brocklehurst P, Tasker RC, Ward Platt MP, Allen
E, Elbourne D. BRACELET Study: surveys of mortality in UK neonatal and
paediatric intensive care trials. Trials 2010,11:65 (26 May 2010).
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
p...
Harvey Marcovitch suggests that it is "good news" that only 4% of
cases are settled in court. Nearly half (43%) are settled out of court.
Is this because in these cases it is not clear to either party whether
there has been negligence or not; or is it because medical attendants have
simply performed below average? At any one time half of us, by
definition, will perform below average. A settlement out of court, to many
people, equates with negligence. So could it be that in 43% of cases,
paediatricians have been deemed negligent when they have simply been
performing below average?
It used to be thought that in half of all cot deaths the cause was medical
negligence. A change in sleeping position brought dramatic improvement,
to show that many paediatricians had suffered false condemnation. Are
paediatricians still being falsely condemned by rushing into out of court
settlements?
In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is...
In their observational study Sammons et al. showed that general
anaesthesia (GA) is more convenient and better tolerated than procedural
sedation (PS) for paediatric neuroimaging.1 These findings are fully
consistent with what can be obviously concluded from recent literature: in
paediatric neuroimaging, and especially in magnetic resonance imaging,
standard sedatives lack optimal effectiveness. The obvious explanation is
the unpredictability of onset, depth and duration of sedation. Although
the incidence of sedation failure is usually below 10%, delay, motion
artefacts, interruption of procedure for supplementary sedation and
interference with scanning schedule occur frequently. In addition, the
long half-life makes an extensive monitored recovery period imperative,
generating an extra burden for health care. Finally, these drugs may cause
unexpectedly deep sedation that might interfere with respiratory
reflexes.2 Their use must therefore be restricted to settings with high
safety standards for monitoring, professional competences and rescue
facilities. From a cost-benefit point-of-view one may question the
justifiability of implying these standards in a sedation practice that
applies suboptimal sedatives. Simply replacing PS by GA is not a
reasonable alternative, given the generally limited anaesthesia services
for neuroimaging.
Recent literature yields interesting new concepts. The anaesthetic
propofol is an excellent sedative for PS in spontaneously breathing
children. Its short induction and recovery times and optimal titratability
make propofol a suitable alternative for GA in neuroimaging.3 Furthermore,
there is good evidence that well-trained non-anaesthesiologists may
provide propofol sedation safely.4 Appropriate safety precautions,
monitoring and professional skills, rather than professional title, are
determinants for its safe and effective use. 5 Time has come to further
explore these concepts and to move to practical implementation. Optimally
safe and effective PS in paediatric neuroimaging needs competent sedation
providers who are specifically trained in deep sedation using highly
effective drugs within a context of transparency and ongoing quality
control.
Piet LJM Leroy1, Hans (J) TA Knape2
1Paediatric Sedation Unit, Department of Paediatrics, Maastricht
University Medical Centre, P.O. Box 5800,
6202 AZ Maastricht, The Netherlands
2Department of Anaesthesiology, University Medical Centre, P.O. Box 85500,
3508 GA Utrecht, The Netherlands
References
1. Sammons HM, Edwards J, Rushby R, et al. General anaesthesia or sedation
for paediatric neuroimaging: current practice in a teaching hospital.
Archives of disease in childhood;96(1):114.
2. Motas D, McDermott NB, VanSickle T, et al. Depth of consciousness and
deep sedation attained in children as administered by
nonanaesthesiologists in a children's hospital. Paediatric anaesthesia
2004;14(3):256-60.
3. Mallory MD, Baxter AL, Kost SI. Propofol vs pentobarbital for sedation
of children undergoing magnetic resonance imaging: results from the
Pediatric Sedation Research Consortium. Paediatric anaesthesia
2009;19(6):601-11.
4. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of
adverse events during pediatric sedation/anesthesia with propofol for
procedures outside the operating room: a report from the Pediatric
Sedation Research Consortium. Anesthesia and analgesia 2009;108(3):795-
804.
5. Green SM, Krauss B. Barriers to propofol use in emergency medicine.
Annals of emergency medicine 2008;52(4):392-8.
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with on...
Eisenhut raises the possibility that food was the source of the
outbreak of group A streptococcal disease at the primary school. This
hypothesis was considered, but was rejected as implausible for several
reasons; firstly the outbreak was not a true point source as it was
preceded by five sentinel cases over a 12 day period, in addition the peak
on the 16th May was inflated as it included cases with onset over the two
day weekend period. The pattern of illness did not suggest any link with
school meal consumption - some of the initial cases were in the reception
class who did not have school meals, a number of the older children among
the initial cases did not have school meals and none of the staff who ate
school meal were ill. The possibility that the school water fountain or
the childrens' water bottles were the source of infection was considered
but neither was compatible with the pattern of illness. Person-to-person
spread, as indicated by the outbreak curve appeared to largely explain the
course of the outbreak.
Eisenhut also comments that exclusion of children with features of
respiratory infection, with the option of immediate treatment of cases
with penicillin rather than waiting for culture confirmation can prevent
secondary cases. This was not our experience, despite the use of the most
rigorous practical exclusion policy and the encouragement of general
practitioners to treat cases symptomatically. We conclude that the
management of contacts requires evaluation as a possible control measure.
Manzano et al present data from a tertiary hospital ER department and
claim that the blood markers are superior to the clinical evaluation. What
is not clear from the data presented is whether there are differences
between them in relation to early or later presentation of illness in this
setting. We have published data previously on the use of procalcitonin in
a similar age group suggesting that this is superior in identif...
Manzano et al present data from a tertiary hospital ER department and
claim that the blood markers are superior to the clinical evaluation. What
is not clear from the data presented is whether there are differences
between them in relation to early or later presentation of illness in this
setting. We have published data previously on the use of procalcitonin in
a similar age group suggesting that this is superior in identifying SBI at
an earlier phase in view of its faster rise in concentration compared to
CRP and other markers.Can the authors analyse their data based on length
of illness?
Refs.
Is procalcitonin a discriminant marker of early invasive bacterial
infection in children?
K Brent, SM Hughes, S Kumar, A Gupta, A Trewick, S Rainbow, R Wall, M
Blair.
Pediatric Academic Societies Annual Scientific Meeting
Presidential Plenary presentation
Seattle USA May 2003
Is Procalcitonin a discriminant marker of invasive bacterial
infection in children ?
K Brent, SM Hughes, S Kumar, A Gupta, A Trewick, S Rainbow, R Wall, M
Blair.
Pediatric Research 2003, 53, 4(2) 20A
I am interesting in the field on how child health research and researchers make attention to gender recognition in:(a) their exposed research methodology and (b) in health interventions, thus, preventive recommendations regarding child health matters.
Therefore, I have recently (2010) published one article concerning the study field "Sudden Infant Death Syndrome" (SIDS) by scrutinizing informatics focusing on gender and sleeping...
I am interesting in the field on how child health research and researchers make attention to gender recognition in:(a) their exposed research methodology and (b) in health interventions, thus, preventive recommendations regarding child health matters.
Therefore, I have recently (2010) published one article concerning the study field "Sudden Infant Death Syndrome" (SIDS) by scrutinizing informatics focusing on gender and sleeping recommendations as published within the Swedish Medical Journal 1980 - 2007 (March 6)[1]. In another paper internationally published key-references, repeatedly highlighted in the Swedish Medical Journal after 1990, are reviewed [2].In these two articles I found that child health research within SIDS epidemiology and intervention showed a strikingly skewed gendered publishing features.
Now to your article [3]. I am not quite sure who you actually asked in the follow-up survey regarding deformation of the head of the child due to strict use of supine sleeping position? The mother, the father, both or from some other caregivers? As a reader of your article I am confused of the matter in question since you state in the discussion (p. 88) that: "Parental concerns about the head shape reduced markedly over time". One line below (p. 88) you confirm:"Indeed, many mothers commented that they had all but forgotten about the head shape issue until they received our letter of the study".
Regarding the first here above quoted statement viz.,"parental concerns"...-- does it covers the view of both the fathers and the mothers? I am asking this since you reveal in the methodological section (p. 86) that the parents actually answered a questionnaire regarding demographic information, obstetric information etc. So, who were asked and who do you men by saying "parents"?
The second statement saying "...mothers commented..." draw in my view attention to ethical premises in follow-up endeavors. Had the fathers the same opinion? Furthermore, in the result section (p. 87)you disclose that "... 59% were not at all concerned". How did you manage such sensitive ethical issue? This question seems me important especially since only a few children still were in the severe stage at T2 and certainly already within health services attention.
References:
1.Brannstrom I. Configurative domains in child health research: Sudden infant death in the Swedish Medical Journal. Policy, Polit Nurs Pract. 2010;11(3):226-234.
2.Brannstrom I. Classification of sudden infant death vs., nursing practices addressed sleeping position: Configurative domains observed in key references. Jour Neonatal Nurs. 2010;16:7-16.
3.Hutchison BL, Stewart AW, Mitchell EA. Deformational plagiocephaly: a follow-up head shape, parental concern and neurodevelopment at ages 3 and 4 years. Arch Dis Child. 2011;96:85-90
Losacco et al's1 review of practice across European neonatal units
regarding the use of non-pharmacological analgesia for painful procedures
in neonatal units has highlighted the relatively infrequent use of these
techniques. This is despite good evidence confirming the effectiveness of
non-pharmocolgical analgesia2 and evidence of deleterious effects of pain
on babies both in short term3 (decreased o...
Losacco et al's1 review of practice across European neonatal units
regarding the use of non-pharmacological analgesia for painful procedures
in neonatal units has highlighted the relatively infrequent use of these
techniques. This is despite good evidence confirming the effectiveness of
non-pharmocolgical analgesia2 and evidence of deleterious effects of pain
on babies both in short term3 (decreased oxygenation, haemodynamic
instability, and raised intracranial pressure) and long term4
(neurodevelopmental delay and altered perceptions of pain in later life).
We have recently conducted an audit on the use of non-pharmacological
analgesia for neonates, comparing our current practice at Good Hope
Hospital, Birmingham, UK against our hospital guidelines. As a part of
this process we have also carried out a review of literature on use of non
-pharmacologic analgesia and assessed if the current hospital guidance
meets evidence based recommendations.
Clinical staff in various neonatal and paediatric clinical areas at
Good Hope Hospital were requested to fill in questionnaires every time
they carried out a painful procedure in an infant. 46 questionnaires were
filled in total; 8 from the postnatal wards, 11 from the childrens'
assessment unit or paediatric ward, and 27 from the neonatal unit.
Ages on postnatal wards for which procedures were carried out ranged
from day 1 to 4. Five of the 8 babies were given sucrose (0.6ml of 24%
solution) which had to be brought up from the neonatal unit, since there
is none available on the postnatal wards. In 2 of the 5 babies additional
non-pharmacological analgesic (NPA) methods were employed (swaddling and
breastfeeding). 2 of the babies not given sucrose were swaddled
Ages for the childrens' assessment unit and paediatric ward ranged
from 2 days to 4 months (the maximum age). 2 of the 11 children were given
sucrose which had to be brought up from the neonatal unit, both were
having a lumbar puncture. One was given 1.3ml of 24% sucrose since the
procedure was prolonged, 3 aliquots of 0.6ml, 0.4ml and 0.3ml were given.
The other was given 0.6ml of 24% solution. For both, additional non-
pharmacological analgesic methods were employed, swaddling for both, and a
dummy for one. 3 of the 11 children were not given sucrose because it was
not available, but additional methods were used (swaddling, breastfeeding
and dummy) for heel pricks and venipuncture. The other 6 babies received
no form of analgesia, procedures included 2 lumbar punctures.
In the neonatal unit the ages ranged from 33+2 weeks gestational age
(our unit only keeps babies above 32 weeks), to 1 month post term-birth
age. 24 of the 27 babies from the neonatal unit received sucrose (0.4ml -
1ml of 24% solution). 18 of the 24 received additional non-pharmacological
analgesia (swaddling, dummy, or both). 6 of the 24 received just sucrose.
3 of the 27 babies did not receive sucrose. One was undergoing the Guthrie
test, the reasoning was it would not take very long to carry out the
procedure, and the baby was swaddled and given a dummy. 1 of the other
babies was nil-by-mouth and so not given sucrose, and the last one was
being given an intramuscular vaccination (Hep B) and the administrator had
the honesty to write they didn't give sucrose, and are not quite sure why
they didn't.
So out of 46 babies who were eligible for sucrose it was given to 31
(~67%), but if considering the neonatal unit alone, this rises to ~92% (24
out of 26 babies). Non-pharmacological analgesic methods were used in
fewer infants (28 out of 46; ~61%) but again, this was used relatively
more often in the neonatal unit (19 out of 27; ~70%). The main reason
given for not using sucrose was its unavailability.
Examination of the literature to produce evidence based hospital
guidelines revealed effective use of non-pharmacological analgesia in the
pre- and post-neonatal period. Hatfield5 et al. used sucrose and non-
nutritive sucking in 100 infants of 2 and 4 months of age undergoing
routine vaccinations in the US, and compared to controls receiving water.
They used the University of Wisconsin Children's Hospital (UWCH) pain
scale to assess pain response at 2, 5, 7 and 9 minutes post vaccinations,
and found a significant difference at each of these time markers with use
of 0.6ml/kg of 24% sucrose. This being just one example, there is
therefore evidence of effective analgesia using sucrose and non-nutritive
sucking for neonates of all gestational ages2 and up to the age of 4
months (even if the efficacy decreases with age requiring higher
concentrations and amounts of sucrose). If the mother and baby are willing
to breastfeed the combination of maternal body contact, so visual, tactile
and olfactory stimuli, breastmilk and suckling on a nipple, are found to
be as effective as sucrose and non-nutritive sucking;6,7 and in low
gestation and/or sick neonates positional forms of analgesia, e.g. prone
positioning, facilitated tucking, swaddling; are found to be especially
effective.8
Since the aim is for effective analgesia in infants of this age, it
would make sense for such resources to be available in all clinical areas
where such procedures are undertaken. In our audit we found this was not
the case, even though babies who may be only a few days old are exposed to
heel-pricks or venipuncture in post-natal wards, or present to children's
assessment units from home, the neonatal unit was the only clinical area
in which sucrose was available and the analgesic guideline was in place.
This was also true for the other hospital within the Heart of England NHS
foundation trust; Birmingham Heartland's Hospital. Combined with the
healthcare staffs' lack of knowledge of effective use of other forms of
non-pharmacological analgesia, this meant such infants received no form of
pain relief compared to babies of similar ages in the neonatal unit where
sucrose is available and neonatal nurses try to ensure concurrent use of
other analgesic methods.
So whereas Losacco et al. found poor compliance with use of analgesic
methods in very low birth weight infants in countries across Europe, we
would argue the problem is larger than that. There needs to be a program
of education for staff working with neonates of all gestational ages and
babies in the first few months of life covering why analgesia is important
at this early age, what methods we have in place which work and how they
are effective, alone or in conjunction. Furthermore, resources (e.g.
sucrose) need to be available in all clinical areas where infants of this
age range receive treatment.
References
1. Losacco V, Cuttini M, Greisen G, et al. Heel blood sampling in European
neonatal intensive care units: compliance with pain management guidelines.
Arch Dis Child Fetal Neonatal Ed 2011; 96: F65-F68.
2. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn
infants undergoing painful procedures. Cochrane Database Syst Rev 2010; 1:
CD001069.
3. Anand KJS, Hickey PR. Pain and its effects in the human neonate and
fetus. N Engl J Med 1987;317:1321?9.
4. Grunau RV, Holsti L, Peters JW. Long-term consequences of pain in human
neonates. Semin Fetal Neonatal Med. 2006;11(4): 268-275.
5. Hatfield LA., Gusie ME., Dyer AM., Polomano RC. Analgesic Properties of
Oral Sucrose During Routine Immunizations ar 2 and 4 Months of Age.
Pediatrics 2008; 121; e327-e334.
6. Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. Analgesic effect
of breast feeding in term neonates: randomised controlled trial. Br Med J
2003;326:13.
7. Gradin M, Finnstrom O, Schollin J. Feeding and oral glucose- additive
effects on pain reduction in newborns. Early Hum Dev 2004;77:57-65.
8. Prasopkittikun T, Tilokskulchai F. Management of pain from heel stick
in neonates. An analysis of research conducted in Thailand. J Perinat
Neonat Nurs 2003;7:304-12.
Woolley's excellent article covers the subject well.
One area where the issue of consent arises fairly frequently is that of vaccination. Although the science is clear that (with a few exceptions for contraindications), vaccination according to the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) and the "Green Book",[1] is generally in the child's best medical interests.
Woolley's excellent article covers the subject well.
One area where the issue of consent arises fairly frequently is that of vaccination. Although the science is clear that (with a few exceptions for contraindications), vaccination according to the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI) and the "Green Book",[1] is generally in the child's best medical interests.
Some parents, however, have anti-vaccine views, and decline vaccination on behalf of their children. When all parties with parental responsibility (PR) are in agreement, this is not an issue. There have been cases, however, in which there has been a conflict. In two such cases, heard together by the appeal court,[2] the judgement was that vaccination with MMR was in the children's best interests and should proceed when the fathers (with PR) wished this, and the mothers did not.
The court, however, felt that the particulars of individual cases - including "the emotional effect on the mothers and the children, and on the bond between them" - should be considered in every case, so this cannot be taken as carte blanche to act in what we perceive to be a child's best interests and vaccinate them if there is a disagreement with the people or bodies with PR for the child.
1. Department of Health, Welsh Office, Scottish Office Department of Health, DHSS (Northern Ireland). Immunisation against infectious disease. London: Department of Health, 2006 (and as amended) (http://www.publications.doh.gov.uk/greenbook/).
2. English R. RE B (A CHILD) sub nom IN RE VACCINATION/MMR LITIGATION : A v B : D v E sub nom IN RE C (A CHILD) (IMMUNISATION: PARENTAL RIGHTS) : IN RE F (A CHILD) (IMMUNISATION: PARENTAL RIGHTS) (2003) [2003] EWCA Civ 1148. 2003; Updated July 2003; Accessed: 2009 (18 November): Recent Cases (http://www.1cor.com/1198/?form_1155.replyids=277).
Dear Editors,
we read with interest the article by Munot et colleagues1 regarding the
possible causative role of anaemia in the pathogenesis of stroke in
children.
Several studies suggest an increased risk of venous and arterial
thromboembolism in adults with inflammatory bowel disease (IBD) compared
to the general population2. We recently performed a systematic review of
studies on incidence and characteristic of throm...
Dear Editors,
we read with interest the article by Munot et colleagues1 regarding the
possible causative role of anaemia in the pathogenesis of stroke in
children.
Several studies suggest an increased risk of venous and arterial
thromboembolism in adults with inflammatory bowel disease (IBD) compared
to the general population2. We recently performed a systematic review of
studies on incidence and characteristic of thromboembolism in children
with IBD3. Out of this review, which used a wide search strategy in
several literature databases, we retrieved the reports of 70 children (age
0-18 years) for a total of 92 thromboembolic events during IBD.
Interestingly, most of the events (54.3%) occurred at cerebral site.
After reading the study by Munot et coll, we reviewed our data considering
the haemoglobin (Hb) levels of children with thromboembolism in IBD.
Information on anaemia was detailed in 42 of the 70 cases: of these, 36
(85%) were reported to be "anaemic". The mean Hb level was 8.6 g/dl, the
median level was 8.7 g/dl, without significant differences between
patients with Crohn's disease and ulcerative colitis (Figure 1). All the
36 anaemic children had a clinically active IBD at the time of TE
occurrence, although activity indexes were not detailed.
The prevalence of anaemia in patients with IBD has been systematically
reviewed and ranges from 8.8% to 73.7% depending on the patient
subpopulation4. The finding that 85% of children with thromboembolism in
IBD were anaemic could suggest that these children represented a
subpopulation with more severe IBD, or that anaemia by itself is an
important additive risk factor for thrombosis during IBD.
More studies are warranted to clarify if anaemia is an independent risk
factor for stroke in children with IBD. Prevention and treatment of
anaemia need to be carefully considered in children with IBD.
Matteo Bramuzzo MD.
Marzia Lazzerini MD, PhD.
Department of Paediatrics, Institute for Child Health IRCCS Burlo
Garofolo, Trieste, Italy.
References
1. Munot P, De Vile C, Hemingway C, et al. Severe iron deficiency
anaemia and ischaemic stroke in children. Arch Dis Child October 27, 2010
2. Grainge MJ, West J, Card TR. Venous thromboembolism during active
disease and remission in inflammatory bowel disease: a cohort study.
Lancet. 2010;375:657-663.
3. Lazzerini M, Bramuzzo M, Maschio M, et al. Thromboembolism in
pediatric inflammatory bowel disease: Systematic review. Inflamm Bowel
Dis. 2010 Dec 3.
4. Wilson A, Reyes E, Ofman J. Prevalence and outcomes of anemia in
inflammatory bowel disease: a systematic review of the literature. Am J
Med. 2004;116:44S-49S
Figure 1. Hb levels in CD and UC patients.
CD: Crohn's disease; UC: ulcerative colitis; Q1: first quartile; Q3: third
quartile.
The child death review procedures in place in England (1) are ideally placed to address the issues that Kenny and Martin raise in their paper on drowning and sudden cardiac death (2). Although rare - there were 43 drowning deaths of 0-19 year olds in England in 2009 (3), such deaths may hide important medical conditions, notably cardiac rhythm disorders.
Following every unexpected child death, a rapid response...
Modi and McIntosh [1] discuss over-regulation of clinical trials and the small number of large neonatal multicentre trials carried out in the UK in 2006.
As there is no single and exhaustive repository of data about UK trials, it is difficult to determine exactly the level of trial activity at that time. We can provide data which include 2006 from a survey of level 2 and 3 neonatal units which identified ran...
Harvey Marcovitch suggests that it is "good news" that only 4% of cases are settled in court. Nearly half (43%) are settled out of court. Is this because in these cases it is not clear to either party whether there has been negligence or not; or is it because medical attendants have simply performed below average? At any one time half of us, by definition, will perform below average. A settlement out of court, to many p...
In their observational study Sammons et al. showed that general anaesthesia (GA) is more convenient and better tolerated than procedural sedation (PS) for paediatric neuroimaging.1 These findings are fully consistent with what can be obviously concluded from recent literature: in paediatric neuroimaging, and especially in magnetic resonance imaging, standard sedatives lack optimal effectiveness. The obvious explanation is...
Editor
Eisenhut raises the possibility that food was the source of the outbreak of group A streptococcal disease at the primary school. This hypothesis was considered, but was rejected as implausible for several reasons; firstly the outbreak was not a true point source as it was preceded by five sentinel cases over a 12 day period, in addition the peak on the 16th May was inflated as it included cases with on...
Manzano et al present data from a tertiary hospital ER department and claim that the blood markers are superior to the clinical evaluation. What is not clear from the data presented is whether there are differences between them in relation to early or later presentation of illness in this setting. We have published data previously on the use of procalcitonin in a similar age group suggesting that this is superior in identif...
Dear Sir,
Losacco et al's1 review of practice across European neonatal units regarding the use of non-pharmacological analgesia for painful procedures in neonatal units has highlighted the relatively infrequent use of these techniques. This is despite good evidence confirming the effectiveness of non-pharmocolgical analgesia2 and evidence of deleterious effects of pain on babies both in short term3 (decreased o...
Some parents, ho...
Dear Editors, we read with interest the article by Munot et colleagues1 regarding the possible causative role of anaemia in the pathogenesis of stroke in children. Several studies suggest an increased risk of venous and arterial thromboembolism in adults with inflammatory bowel disease (IBD) compared to the general population2. We recently performed a systematic review of studies on incidence and characteristic of throm...
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